Full Legal Name
Middle
Date of Birth
Gender
UT Residence Address
Social Security Number or ITIN This information will not show on your driver license or ID card
City Zip Code
Mailing Address City State Zip Code
Height Weight FT. IN.
Hair Color Eye Color
Applicant’s Mother’s Place of Maiden Birth State/Country Name Last First
NOTICE: APPLICANT MUST ANSWER ALL QUESTIONS.
Print the name of the person signing for minor:
Father Mother Guardian
DLD6a Rev. 5/18
DLD Office Use Only:
EL LERN ORG LERN
DPC DL CDL ID IDD
LTID LTDL LTCDL MVP
Class: A B C D
End. H N X Z P S T M
Visual Acuity: Passed Eye Statement
Restrictions: A B K L G V 6
Motorcycle Restrictions: 2 3 5
Testing: Written Road Ref/Asyl
CDLIS: CSOR ADD DRIVER
CDL:
YES
YES NO
YES
PDPS: SB:________________________________
License Surrender: NO
IDC: NO
Iss.: _____________ Exp: _____________
State: ___________ End.: _____________
License #: __________________________
Total $: __________ Trans #: __________
Initials: ______
Date Stamp: ________________________
YES NO Are you a U.S. Citizen? YES
YES
Are you a legal permanent resident alien or a U.S. National?
If you are a citizen of another country, do you have evidence of lawful presence in the United States?
YES NO
YES NO
YES
YES
NOYES
NO
NO
NO
YES
YES NO
YES NO
YES NO
YES NO
Do you claim to be disabled under the Americans with Disabilities Act?YES
NO
UT LICENSE # UT ID #
J:____________________
Translator: Y / N
Station Code: ___ Emp. #: ___ Initials: ___
Name Change:
From: _____________________________
To: _______________________________
ID #1: _____________________________
ID #2: _____________________________
Address Verified: ____________________
Full Legal Name:
__________________________________
DOB: __________ Iss Date: ___________
BC PP DHS #: ______________________
Iss. Agency: ________________________
Required Docs Scanned: YES
SSN: _______________ Date: __________
SAVE: Approved/Exp.: ________________
Emp. #: __________ Date: _____________
FirstLast Suffix
Number/Street/Apartment
mm/dd/yyyy
Email Address Phone
YES NO
I would like to register my desire to help others by being an organ, eye, and tissue donor (life-saving anatomical gift.)
Are you a U.S. Military Veteran?
If yes, do you authorize sharing this information with the Utah Division of Veterans Affairs for the purpose of identifying veterans and disseminating veteran benefit information?
If you have been honorably discharged from the U.S. military, would you like to have a VETERAN indicator on your driver license or ID card? Provide a DD214 or Veterans Record/Notice of Separation indicating an honorable discharge.
Are you required to register as a sex offender with the State of Utah, any other state, or with the U.S. Government?
Have you ever been issued, a driver license by another state, country or province? If yes, list states/countries/provinces: ____________ # ____________ Exp. __________
If you are a CDL driver, have you been licensed in another state within the last 10 years? If yes, please list: _____ # ____________ I _____ # ____________
In the last 10 years, has your driving privilege been suspended, revoked, canceled, denied or disqualified? If yes, State: _____ # ____________Why? _______________________________________________________________
YES NO
YES NO
NO
Do you wish to contribute a $2.00 donation to the "Friends for Sight" fund?
Do you wish to contribute a $2.00 donation to educate people about organ, eye and tissue donation?
Do you wish to contribute a $1.00 donation to the "Mobility Assistance Fund?"
Do you claim to be disabled under the Americans with Disabilities Act?
Do you claim to be indigent and are applying for an ID card for voting purposes?
_________________________ __________________________ ________________________ ______
_____________________ __________________________
PO Box/Number/Street/Apartment_____________________
_____________________
_________________________________ ________ ________
___________________________________________
_______________________________________________ _____________________
_____ _____ _______
_______________________________________ ______________________ ______________________
___________________________________________
UT LICENSE # UT ID #
Applicants who apply for or hold a license are responsible to report physical or mental health conditions to the division. DO YOU HAVE, OR HAVE YOU HAD, ANY OF THE FOLLOWING CONDITIONS IN THE LAST FIVE YEARS?
Diabetes:
Cardiovascular:
Pulmonary:
Neurologic:
Epilepsy:
Alcohol & Other Drugs:
Vision:
Musculoskeletal:
Alertness or SleepDisorders:
YES
YES
YES
YES YES
NO
NONONO
NO
YES NO
YES NO
YES NOYES NO
YES NO
YES NO
YES NO
YES NO
YES
YES
YESYESYES
NO
NONONO
NO
Other:
Do you take insulin?
Do you have an uncontrolled heart condition?Do you have an implantable cardioverter defibrillator (ICD)?Have you lost consciousness or fainted in the last five years?
Do you have a pulmonary (lung) condition?Is an inhaler the only medication prescribed for this condition?Do you use supplemental oxygen?
Do you have, or have you had a neurological condition such as: Dementia, strokes, Alzheimer's, traumatic brain injury, Multiple Sclerosis, or Parkinson's?
Do you have or have you had seizures in the last five years? Or,Commercial Driver: Anytime during your life?
Do you have learning and memory difficulties which may interfere with driving safety?
Do you have a mental health condition such as schizophrenia, severe anxiety, or severe depression?
Do you use alcohol excessively, misuse prescription drugs, or use illegal drugs?Have you been treated for alcohol or chemical dependency, or has treatment been recommended by a medical professional?
Are you required to wear glasses or contact lenses for driving?Is your visual acuity worse than 20/40 in the better eye, even with corrective lenses?Do you have a degenerative or progressive eye condition?Have you experienced a decrease in peripheral (side) vision?
Do you have loss or paralysis of all or part of a limb, or severe arthritis?New or changed in the past 5 years?Present longer than 5 years?
Do you have a condition that produces abnormal sleepiness (sleep apnea, narcolepsy, etc.)?
Are there any other health problems or use of medications which might interfere with driving ability or safety or control of a vehicle? Please explain:______________________________________________________________
YES
YES
YES
NO
NO
NO
YES NOYES NO
Learning & Memory:
Mental HealthConditions:
Answering yes to any of the above questions may result in your receiving a request for additional follow-up information.
Do you authorize the use of information in this form for voter registration purposes?
Any voter may register as an absentee voter to receive ballots by mail. A voter may change this designation at any time. Would you like to be registered as an absentee voter to receive ballots by mail?
To register or preregister to vote in Utah, you must be a citizen of the United States, have resided in Utah for 30 days immediately before the next election, and not be a convicted felon currently incarcerated for a felony. You must be 16 or 17 years old to preregister to vote or at least 18 years old on or before the next general election to register to vote. If you decline to register to vote, the fact that you have declined will remain confidential and will be used only for voter registration purposes. If you register to vote, the office with whom you register will remain confidential. The portion of your voter registration form that lists your license or identification card number, social security number, email address, and the day of your month of birth is a private record. The portion of your voter registration form that lists your month and year of birth is a private record, the use of which is restricted to government officials, government employees, political parties, or certain other persons. In order to be allowed to vote in a voting precinct for the first time or to vote during the early voting period before the date of the election, you must present valid voter identification to the poll worker before voting as follows: (1) a valid form of photo identification that shows your name, photograph, and current address; or (2) two different forms of identification that show your name and current address.
VOTER REGISTRATIONYES
YES
YES
NO
NO
NO
Political Party: Constitution Democratic Green Independent American Libertarian Republican United Utah Unaffiliated Other___________________
CITIZENSHIP AFFIDAVIT/VOTER DECLARATIONI hereby swear and affirm, under penalties for voting fraud set forth in Utah Code Sec. 20A-2-401 that I am a citizen of the United States and that to the best of my knowledge and belief the information I have given is true and correct. I do swear (or affirm), subject to penalty of law for false statements, that the information contained in this form is true, and that I am a citizen of the United States and a resident of the State of Utah, residing at the above address. Unless I have indicated that I am preregistering to vote in a later election, I will be at least 18 years of age and will have resided in Utah for 30 days immediately before the next election. I am not a convicted felon currently incarcerated for commission of a felony.
DLD Office Use Only: Examiner Notes
x___________________________________________ Date: ___________________Sign ABOVE to register to vote.
I would like to request that my voter registration record be classified as a private record.
UT LI CENSE # UT ID #
PLEASE STOP AND TAKE THE COMPLETED FORM TO AN EXAMINER
FAILURE TO TRUTHFULLY COMPLETE QUESTIONS MAY RESULT IN WITHDRAWAL OF DRIVING PRIVILEGE OR IDENTIFICATION CARD.
By submitting this application, I am consenting to registration with the Selective Service System, if required by federal law. Refusal to consent to the release of information to the Selective Service System shall result in the denial of the license and/or identification card.
Implied Consent - By operating a motor vehicle in this state you have given consent to a chemical test of your breath, blood, urine, or oral fluids for the purpose of determining if you are operating or in actual physical control of a motor vehicle while having a blood or breath alcohol content or are under the influence of drug or a combination of both that is prohibited by Utah law.
ID AFFIDAVIT: I, the undersigned, under penalty of perjury affirm that I am the applicant described on this application and that the information entered herein is true and correct to the best of my knowledge. I acknowledge cancellation and surrender to the Driver License Division, where possible, of any previously issued license certificates or ID cards.
X_______________________________________________________________________ hereby affirmed __________ day of _______________ 20 _____
I, ____________________________________ give permission for the described applicant, who is under 16 years of age, to obtain a Utah Identification card.
DL AFFIDAVIT: I, the undersigned, under penalty of perjury affirm that I am the applicant described on this application and that the information entered herein is true and correct to the best of my knowledge. I acknowledge cancellation and surrender to the Driver License Division, where possible, of any previously issued license certificates or ID cards. I hold harmless the State of Utah, its political subdivisions and employees for damage or injury that may occur during a driving test, should one or more be required of me. I agree I will allow the State of Utah to administer any additional driving skills tests at any future date in order to demonstrate my ability to operate a motor vehicle.
X_______________________________________________________________________ hereby affirmed __________ day of _______________ 20 _____
ASSUMPTION OF LIABILITY FOR MINORS UNDER EIGHTEEN YEARS OF AGE: I, the undersigned, under penalty of perjury state that I have read the statements made in this application and that they are true and correct to the best of my knowledge. I hereby consent to assume the obligation imposed under Section 53-3-211 Utah Code Annotated 1953 as amended, of being jointly and severally liable with the applicant for any damages caused by his/her negligence or willful misconduct while he/she is under the age of eighteen years while driving a vehicle upon a highway.
X_______________________________________________________________________ hereby affirmed __________ day of _______________ 20 _____
I CERTIFY THAT: Said applicant has completed 40 hours of driving, of which at least ten hours were after sunset, in compliance with Utah Code Annotated Section 53-3-211 or 53-3-210.5 Utah Code Annotated 1953 as amended.
X_______________________________________________________________________ hereby affirmed __________ day of _______________ 20 _____
CDL AFFIDAVIT: I hereby state, under penalty of perjury affirm that I am the applicant described on this application and that the information entered herein is true and correct to the best of my knowledge. I am of legal age to obtain the driver license for which I have applied, and that I have been a licensed driver for at least one year. I acknowledge cancellation and surrender to the Driver License Division, where possible, of any previously issued license certificates or ID cards. I hold harmless the State of Utah, its political subdivisions and employees for any damage or injuries that may occur during, or as a result of my driving skills test(s). I agree I will allow the State or Federal Government to administer any additional Pre-Trip, Basic Control Skills, and On-Road Driving tests at any future date in order to demonstrate my ability to operate a commercial motor vehicle. I certify that I meet all requirements in 49 CFR Part 383.73 and that my driving privilege is not suspended, disqualified, revoked or denied in this or any other state.
X_______________________________________________________________________ hereby affirmed __________ day of _______________ 20 _____
STATE OF UTAH, COUNTY OF ____________________________ _____________________________________________________
_____________________________________________________
Parent/Legal Guardian
Day Month Year
Day
Day
Day
Day
Month
Month
Month
Month
Year
Year
Year
Year
Person authorized to administer oaths
Employee initials and number Station Code
